Framework for Injection Drug User (IDU) Health and Wellness

The purpose of this document is to encourage the State of California Department of Public Health, Office of AIDS (CDPH/OA), other policy makers, and those responsible for the design and delivery of HIV prevention and care services to develop a broad initiative based on the Framework for IDU Health and Wellness.

The Framework for IDU Health and Wellness was written by the California HIV Planning Group’s (CHPG) Substance Use/IDU Task Force in collaboration with CDHS/OA staff and in consultation with community experts. It was inspired by the Framework for Gay Men’s Health and Wellness, which was developed in 2004 by the Gay Men’s Task Force of the CHPG. In that document, the authors state that the Task Force concluded that “sustained HIV prevention efforts have faltered, in part, because they focused singularly on a disease—AIDS—rather than focusing on the diverse health and wellness of gay men…[H]ealth promotion must be the platform and disease prevention one of the planks among all health-related initiatives targeting gay men. HIV prevention, therefore, must begin with promoting overall health and wellness including physical, mental, spiritual, and sexual.” A similar comprehensive approach is emerging as best practice for HIV prevention and care for IDUs. The World Health Organization and the Centers for Disease Control and Prevention are among the organizations that have recommended comprehensive services as the most effective way of preventing HIV for IDUs and other drug users.

Premise

The Substance Use/IDU Task Force asserts that one of the best ways to discourage self-destructive behaviors is to foster value for health and wellness among drug users, as well as a sense of worth and self-acceptance that is not contingent upon abstinence from drugs. The Framework emerges from the philosophy of harm reduction, which holds as one of its key principles that drug users are treated with dignity and as full members of society. The harm reduction model holds much in common with strength-based models of social work and social change, which emphasize the assets of individuals and communities over their deficits.

It is crucial to recognize that the social stigma that exists in this country against injection drug use is institutionalized in ways that affect the health and wellness of IDUs and their communities. This stigma probably deters many people from beginning injection. However, once a person begins injection, that same stigma can pervade every aspect of an individual’s life, determining where and how they live, whether or not they receive health care, whether they are treated well or poorly in many different situations and whether they are free or imprisoned. Incarceration increases risk of disease transmission and overdose, and further jeopardizes IDU health. Homophobia, sexism, racism, ageism, classism, and other oppressions that IDUs face, and sometimes perpetrate, also affect IDU health. Additionally, it is well documented that IDUs of color disproportionately bear the burden of HIV disease. Drug using youth also experience multiple oppressions resulting in health disparities. Understanding the debilitating effects of discrimination must be a priority for research, service design and delivery.

Key Principles

The Framework for IDU Health and Wellness is based on the following key principles:

Drug users have a right to protect their own health and the health of those around them.

Drug users should have the means by which to protect their health, including access to sterile injection equipment sufficient to meet their needs.

All drug users should receive accurate, non-biased and non-judgmental information on illicit drugs and other substances.

All drug users should receive the same level of care as any other individual accessing health care or social services.

Drug users should have access to drug and alcohol treatment on demand.

Providers should recognize the valid and valuable expertise that people who use drugs can give to designing, delivering and evaluating effective services.

Health care and social service professionals should ensure that the provision of services to drug users is not contingent upon the individual’s agreement to enter drug treatment, or abstain from drug use. Service providers must not withhold appropriate treatments or services from drug users.

Services should be provided in a manner that encourages engagement and retention in care.

Background

Injection drug use has been a familiar aspect of California community life for many decades. With some notable exceptions, state and local governments have not successfully addressed the complex social and medical needs of IDUs who are not in drug treatment programs. The emphasis on identifying and serving the needs of IDUs outside of the drug treatment system is important: research indicates that fewer than one-half of all injectors report having ever used any substance abuse treatment services in their lifetimes.

In California, drug users, their allies and advocates started rallying around issues of IDU health in the 1980s, when syringe exchange programs (SEPs) were first established in order to reduce the risk of HIV infection for drug users, their partners and families. Despite considerable legal and social barriers, IDUs and their allies were successful in establishing over 40 SEPs in California, and in integrating services for drug users into countless other health and social service programs in the state. Numerous success stories point to the little-recognized fact that IDUs have been successfully taking responsibility for their own health and the health of their communities for many years.

Community-Based Organizations (CBOs) are crucial points of intervention and care. People who use drugs interact with virtually every social service system in California. Syringe exchange programs have taken the lead to engage and serve current injection drug users, however, there remain many untapped opportunities for community-based service programs to help reduce negative health outcomes for drug users, and enhance drug user health and wellness.

Some of the actions CBO may take include:

Provide safer injection education to all active drug users.

Offer overdose prevention education and response, and distribute naloxone[1], especially to people who have recently been incarcerated;

Examine policies which exclude active drug users or limit their program participation by referring potential program participants to other agencies rather than serving them directly;

Recognize the expertise drug users have by training and employing them as volunteers and staff;

In regions where syringe access is limited by law, provide ancillary materials, such as cookers and sterile water, in order to protect IDU health;

Ensure that staff is trained to provide education and treatment referral for significant IDU health issues, including hepatitis, abscess prevention and wound care;

Ensure referrals to drug treatment are up-to-date, and include referrals to buprenorphine and methadone maintenance therapy where available;

Ensure that staff is educated in the effects of incarceration on IDU health and is able to provide services which reduce its negative impacts.

Prioritized Recommendations

The Task Force developed three major recommendations. The first advocates for the adoption of the health and wellness framework, while the second speaks directly to HIV/AIDS service providers and advocates for specific improvements in quality of service. The third addresses dissemination of the Framework for IDU Health and Wellness.

1) Promote and advocate for IDU health and wellness through the inclusion of harm reduction policy in services to IDUs funded by CDPH/OA.

This will be accomplished by:

a) Developing a California cross-agency task force to address the health and wellness needs of IDUs in California. The cross-agency task force will develop a working, evidence-based definition of harm reduction to provide guidance to funded agencies;

b) Developing and enhancing relationships with SEPs, AIDS Service Organizations (ASOs), drug treatment providers, law enforcement, mental health providers, pharmacists, medical personnel and others to help with the implementation of the IDU health and wellness campaigns.

2) Develop technical assistance and capacity building for local health jurisdictions, CBOs, and community HIV planning groups in the design, delivery, and evaluation of appropriate and effective HIV prevention and health services for IDUs in California.

This will be accomplished by:

a) Developing a comprehensive IDU health curriculum based on the Framework for CDPH/OA-funded providers;

c) Providing a comprehensive IDU health curriculum to community partner organizations to ensure the providers’ competence working with drug users;

d) Offering technical assistance and capacity building to CDPH/OA-funded providers that request and/or require it to ensure competence while providing HIV and STD prevention, HIV health services, and health promotion for IDUs in California.

4) Include by reference this framework into CDPH/OA contracts for services to IDUs, and develop a procedure that incorporates compliance and oversight with this framework into the contract monitoring process.

[1]Naloxone, sometimes known by the brand name Narcan, is an opiate antagonist used to reverse the effects of an overdose.